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You don’t have to face this alone. Whether you need help for yourself, someone you care about, or your entire community, we’re here.

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Thank you for your response. ✨

Who needs support?(required) Myself Someone else Community/School

Your Name(required)

WhatsApp/Phone Number(required)

Parish(required)

What are you struggling with? (Check all that apply) Anxiety or constant worry Sadness or depression Hurricane trauma/PTSD Loss or grief Can't sleep Anger or irritability Family stress Just need someone to talk to Other (please describe below)

How would you prefer to receive support?

How urgent is your need?

Their Name (Optional)

Their Age Group

Your relationship to them

What concerns do you have? (Check all that apply) Withdrawn or isolating Behavior changes Extreme mood swings Not eating or sleeping Regressing (bedwetting, baby talk) Excessive fear or worry Aggression or anger Talking about death or hopelessness Other concerning behaviors

Are they aware you're requesting help?

Organization/School Name(required)

Type of Organization

Your Role

Approximate number of people needing support

What type of support would help? (Check all that apply) Day camps for children/teens Group counseling sessions Individual counseling on-site Training for teachers/staff Parent support workshops Crisis response team Ongoing wellness programs Community needs assessment

Do you have space available for programs?

Is there anything else we should know?

Best time to contact you

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